Provider Demographics
NPI:1225725203
Name:GREAT LAKES EYE SURGERY LLC
Entity type:Organization
Organization Name:GREAT LAKES EYE SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARHAD
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHOKOOHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-793-2820
Mailing Address - Street 1:5623 E DUNBAR RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9127
Mailing Address - Country:US
Mailing Address - Phone:734-241-3891
Mailing Address - Fax:
Practice Address - Street 1:2393 SCHUST RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1334
Practice Address - Country:US
Practice Address - Phone:734-241-3891
Practice Address - Fax:734-241-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty